Infant care practices and parent uptake of safe sleep messages: a cross-sectional survey in Queensland, Australia

Maternal depressive symptoms and mother-infant cosleeping (including room sharing and bedsharing): a systematic review

STUDY OBJECTIVES

Maternal depressive symptoms (MDS) affect most women during the first year postpartum. Mothers provide most of the nighttime care for infants, so studying the relationship between MDS and infant sleep location (ISL) is highly relevant to understanding maternal mental health over the first year of life and beyond. Infant sleep is studied by anthropologists, health care providers, and psychologists, with very little communication across disciplines. This review aimed to determine whether there is a predictive relationship between MDS and ISL.

METHODS

This systematic review searched 6 databases with terms related to maternal mood and ISL. Final analysis included 14 published studies, analyzed with narrative synthesis and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies directly compared ISL and MDS.

RESULTS

Five studies showed no relationship between ISL and MDS, and 1 study found bedsharing reduced MDS. Five studies found cosleeping was related to higher MDS although directionality is mixed or missing, and 3 studies found an association at some ages or for some populations only. Examining studies according to type of infant sleep assessment, study design, age of infant, or breastfeeding status failed to detect consistent patterns.

CONCLUSIONS

A variety of study designs, types and definitions of variable measures, sample recruitment, and study outcomes prevent detection of a consistent relationship between MDS and ISL. We explore reasons for the elusive nature of a relationship and make recommendations for future research in MDS and ISL, including crossdisciplinary collaborations.

CITATION

Barry ES, D'Souza L. Maternal depressive symptoms and mother-infant cosleeping (including room sharing and bedsharing): a systematic review. J Clin Sleep Med. 2024;20(9):1517-1533.

Sleeping Like a Baby: An Investigation of Bed-Sharing, Co-Sleeping, and Breastfeeding Among Pregnant Adults During the COVID-19 Pandemic

Introduction: Given the lack of clarity in the literature related to the impact of breastfeeding intentions on sleeping practices, the current research aimed to investigate the relationship between co-sleeping or bed-sharing and breastfeeding intentions among a sample of pregnant adults, during the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: Pregnant adults from a large nationally representative sample, responded to a one-time, online Qualtrics survey between October and November 2020. Pregnant adults (n = 544) were asked closed and open-ended questions about their family characteristics, sociodemographic factors, sleeping and breastfeeding habits, and intentions. This protocol was approved by the Wesleyan University Institutional Review Board. Results: Bed-sharing (odds ratio [OR] = 2.47) and co-sleeping (OR = 3.52) intentions doubled and tripled, respectively, intentions to breastfeed at 3 months. Additionally, income at some higher levels (i.e., $150,000+/year) significantly increased breastfeeding intentions at 3 months compared with the lowest income category (OR = 5.74, p = 0.011). There was also a significant relationship between intentions to bed-share (OR = 2.96, p = 0.012) and co-sleep (OR = 3.62, p < 0.001) with breastfeeding at 6 months. Prior breastfeeding experience was significantly associated with breastfeeding intention at 6 months (OR = 1.88, p = 0.035). Based on the qualitative findings, breastfeeding ease was by far the most common motivation for co-sleeping or bed-sharing, followed by security/safety, closeness, and past experience. Conclusion: Plans to bed-share and co-sleep, significantly increased the odds of breastfeeding intentions up to 6 months postpartum. Supporting breastfeeding should include conversations about parent-infant sleeping modality, style, and preference. Future research is necessary to understand the directional impacts of these decisions and the predictive role of prenatal intentions on postpartum behaviors in this context.

Does Exposure to Pediatrician or Parent Blog Content Influence Infant Safe Sleep Practices?

OBJECTIVE

To examine whether exposure to safe sleep recommendations using a blog format changed infant sleep practices.

METHODS

We conducted a pilot randomized controlled trial via Qualtrics, a web-based platform, with a national sample of parents of children < 1 year old. Survey questions about infant sleep practices included: bed-sharing, location, position and objects present. Safe sleep was defined as not bed-sharing, in a crib, bassinet or playard, back positioning, and no other objects present except pacifiers. Participants were randomized to read one of the following: (1) pediatrician blog post, (2) parent blog post, or (3) no blog post. The blog posts contained the same content about infant sleep but varied by identified authorship. All participants received links to online content about safe sleep. Participants received a follow-up survey 2-4 weeks later with the same questions about infant sleep practices. We compared responses in pre- and post-surveys by type of blog post exposure using multivariable logistic regression models.

RESULTS

The average infant age (n = 1500) was 6.6 months (Standard Deviation 3.3). Most participants (74%) were female; 77% were married; 65% identified as white Non-Hispanic, 12% were black and 17% were Hispanic. 47% (n = 711) completed both surveys. We identified no differences in the odds of any of the four safe sleep practices after exposure to safe sleep recommendations in blog post format.

CONCLUSION

Although in-person advice has been associated with improved safe sleep practices, we did not identify changes in infant sleep practices after exposure to safe sleep advice using blog posts.

Infant Care Practices, Caregiver Awareness of Safe Sleep Advice and Barriers to Implementation: A Scoping Review

Modifiable infant sleep and care practices are recognised as the most important factors parents and health practitioners can influence to reduce the risk of sleep-related infant mortality. Understanding caregiver awareness of, and perceptions relating to, public health messages and identifying trends in contemporary infant care practices are essential to appropriately inform and refine future infant safe sleep advice. This scoping review sought to examine the extent and nature of empirical literature concerning infant caregiver engagement with, and implementation of, safe sleep risk-reduction advice relating to Sudden Unexpected Deaths in Infancy (SUDI). Databases including PubMed, CINAHL, Scopus, Medline, EMBASE and Ovid were searched for relevant peer reviewed publications with publication dates set between January 2000–May 2021. A total of 137 articles met eligibility criteria. Review results map current infant sleeping and care practices that families adopt, primary infant caregivers’ awareness of safe infant sleep advice and the challenges that families encounter implementing safe sleep recommendations when caring for their infant. Findings demonstrate a need for ongoing monitoring of infant sleep practices and family engagement with safe sleep advice so that potential disparities and population groups at greater risk can be identified, with focused support strategies applied.

Safe Sleep Behaviors and Factors Associated With Infant Second Sleep Practices

OBJECTIVES

To examine the prevalence and safety of infant second-sleep practices.

METHODS

A cross-sectional online survey of parents with infants ≤12 months assessed parent-reported sleep practices: position, use of a separate sleep surface, and sleep location at 2 time points (sleep onset and after nighttime waking). A composite score examined if all 3 safe sleep practices were used at each time point. Safe sleep was defined as: supine position, sleeping in a separate space, and in a crib, bassinet, cradle, or playard. Wilcoxon sign rank test was used to examine changes between the time points. Poisson regression models compared parents who reported a second-sleep location with those who did not.

RESULTS

Of participants (n = 1500), 74% were female, 65% were White, 12% were Black, and 17% were of Hispanic ethnicity. Thirty-nine percent (n = 581) reported a second-sleep practice. Of parents who reported a second-sleep practice, 28% (n = 137) met all 3 safe sleep criteria at sleep onset; 9% (n = 42) met all 3 safe sleep criteria at both time points. A higher proportion of changes in sleep practices were to less-safe practices (P <.001). Factors associated with a second-sleep practice were parental age <25 years, parental race and ethnicity, first-time parents, homes with smoke exposure, and infants born at <37 weeks.

CONCLUSIONS

Less than 10% of infants met all 3 safe sleep criteria at sleep onset and after nighttime waking. Interventions focused on safe sleep should highlight the importance of safe sleep practices after nighttime waking.

A qualitative study of the sleep ecology of infants under 2 years old and their mothers in South Korea

OBJECTIVES/DESIGN

Infancy is a crucial period for establishing an individual's sleep pattern, and it is a common period during which infants and mothers experience sleep problems. The aim of this qualitative study was to explore the sleep ecology of infants under 2 years of age and their mothers.

SETTING/PARTICIPANTS

The study participants were 20 mothers with infants aged 3-19 months living in South Korea.

METHODS

Data were collected through in-depth interviews and analyzed using the thematic analysis.

RESULTS

Five themes related to the sleep of infants and their mothers emerged from the data: (1) changes in sleep patterns, (2) room-sharing, (3) environmental factors affecting sleep, (4) efforts to improve sleep quality, and (5) infant sleep and the mother's health. The sleep patterns of infants and their mothers were mutually interrelated, and were strongly affected by various environmental factors, including infants' biological maturity (a microsystem) as well as cultural factors (a macrosystem). Culture had an especially profound effect on sleep patterns of infants, similar to the effects of microsystem-level factors.

CONCLUSIONS

To improve the sleep quality of infants and mothers, an ecological approach considering the biological characteristics and cultural contexts of infants is required based on an understanding of sleep as a phenomenon that evolves in a relationship of mutual influence between infants and mothers.

Challenges parents encounter when implementing infant safe sleep advice

AIM

To understand which safe sleep recommendations parents find most challenging to implement, identifying common barriers encountered; and investigate whether challenges are associated with practices employed.

METHODS

A cross-sectional survey of 3341 Australian families with young infants who birthed a live baby during April-May 2017. Caregivers were asked about infant care practices and family characteristics. Qualitative free-text items explored challenges faced with current safe sleep recommendations.

RESULTS

Nearly one-third (n = 1033, 31%) of caregivers reported difficulty with at least one safe sleep recommendation. Infant sleep position and avoiding bed-sharing were identified as the most challenging recommendations. Caregivers described barriers which influenced consistency in uptake of advice. Families who described difficulty with a recommendation were significantly less likely to consistently employ that advice compared to those who did not report difficulty (sleep position: 198/473,42% vs 2548/2837,90% [p < 0.0001]; own sleep space: (269/344,78% vs 1331/2884,46% [p < 0.0001]). When families encountered challenges, they often proposed alternate strategies with an inference their substitute action compensated potential increased risk.

CONCLUSION

Many families encounter difficulties implementing safe sleep advice; these challenges negatively impact care practices. Effective interventions meeting individual family needs, to provide safe sleep environments consistently, are necessary to improve sleep-related infant care and further reduce infant mortality.

A Box to Put the Baby in: UK Parent Perceptions of Two Baby Box Programmes Promoted for Infant Sleep

Between 2016 and 2019, two different infant sleeping-box interventions were implemented in England: (1) shallow polypropylene baby boxes were distributed via a feasibility study to families with Sudden Infant Death Syndrome (SIDS) risk factors; and (2) a commercial–health system partnership scheme distributed cardboard baby boxes to new mothers in particular locations. We conducted parent evaluations of both interventions at the time of implementation. The views of 79 parents receiving polypropylene boxes and 77 parents receiving cardboard boxes were captured using online questionnaires and telephone interviews. Participants provided feedback on education received about using the box, their perception of the box design and materials, their experiences of using the box they received, and whether they would recommend it to others. Parents appreciated that both boxes provided a portable space to place their baby near them anywhere in the home, discouraging other riskier practices. The polypropylene box was rated more favourably regarding transparency, hygiene, and portability outside the home. A minority of parents found the idea of putting their baby in any box unappealing; however, younger mothers and smokers particularly appreciated the ability to safely co-sleep with their babies using the shallower box. Overall, the versatility of the polypropylene box scheme was more positively evaluated than the cardboard baby box scheme, which, stripped of its social value as part of a larger welfare provision, had minimal value for parents that received it.

Priority setting: Consensus for Australia's infant safe sleeping public health promotion programme

AIM

To develop focused priorities to inform the revision of Australia's Sudden Unexpected Death in Infancy (SUDI) risk reduction public health programme.

METHODS

A content expert consensus research activity was designed using two consensus techniques. The two-phase study employed a Delphi process (phase 1) and a Nominal Group workshop technique (phase 2). The Delphi invited 56 national and international content experts. The Nominal Group comprised 17 Australasian experts and stakeholders to ensure priority setting was relevant to the Australian context.

RESULTS

Phase 1 established a ranked thematic list of 10 key SUDI risk reduction themes. Phase 2 addressed three nominal questions producing prioritised lists for: key-message wording; contextual information and strategies to support caregiver implementation of key messages; and considerations in redesigning and dissemination of a safe sleep campaign. The top four priority themes were: sleep position, sleep space, smoking and surface-sharing.

CONCLUSION

This two-phase priority setting was successful in establishing clearly defined infant safe sleep priorities. International content expert participation in phase 1 strengthened priority setting outcomes while phase 2 ensured final outcomes provided a strong national focus reflective of identified needs of Australian families. Findings provide a foundation from which important components can be considered when revising and developing future SUDI risk reduction programmes.

The Impact of the Economic Corridor on Economic Stability: A Double Mediating Role of Environmental Sustainability and Sustainable Development Under the Exceptional Circumstances of COVID-19

This study discusses the impact of different economic indicators on economic stability, including honest leadership, improved infrastructure, revenue generation, and CPEC taking into account the double mediating role of environmental sustainability and sustainable development, while considering the latest COVID-19 situation. This study adopted primary data collection methods and obtained data from the employees of CPEC by using questionnaires and smart-PLS for analysis purposes. The results revealed that honest leadership, improved infrastructure, revenue generation, and CPEC have a positive nexus with economic stability. Despite the severe impact of COVID-19 on the country’s economy, the economic corridor plays a vital role in stabilizing the state’s economy and supports all those related to this phenomenal project either directly or indirectly.

Awareness of infant safe sleep messages and associated care practices: findings from an Australian cohort of families with young infants

OBJECTIVE

To investigate primary infant caregiver awareness of the current national public health safe sleep messages and the associations of awareness with care practices.

DESIGN AND SETTING

A cross-sectional survey in Queensland, Australia. All families with live babies birthed during April-May 2017 were eligible. Questionnaires were distributed when infants were approximately 3 months old.

PARTICIPANTS

Of the 10 200 eligible families, 3341 (33%) primary caregivers participated.

MAIN OUTCOME MEASURES

Participants were asked: to recall key safe sleeping messages they were aware of (unprompted); questions about their infant care practices; and to select the current, national six safe sleeping messages (prompted multi-choice).

RESULTS

Overall, the majority of families are aware of sleep-related infant mortality and sudden infant death (3178/3317, 96%); however, approximately one in four caregivers (867/3292, 26%) could not identify the current six messages to promote safer infant sleep in a multi-choice question. Despite being aware of the six key messages, some caregiver practices did not always align with advice (336/2423, 14% were not smoke-free; 349/2423, 14% were not usually supine for sleep; 649/2339, 28% employed practices which may increase risk of head or face covering; 426/2423, 18% were not receiving breastmilk).

CONCLUSIONS

There is considerable scope for improvement in parent awareness and ability to recall key safe sleep messages. Awareness of advice does not always translate into safe infant care. Health promotion messaging to encourage safer infant sleep, ultimately aimed at reducing sudden unexpected infant deaths, needs more effective supportive strategies and dissemination if future campaigns are to be successful.

Applying a Social Exclusion Framework to Explore the Relationship Between Sudden Unexpected Deaths in Infancy (SUDI) and Social Vulnerability

Background: Sudden Unexpected Death in Infancy (SUDI) is a leading cause of preventable infant mortality and strongly associated with social adversity. While this has been noted over many decades, most previous studies have used single economic markers in social disadvantage analyses. To date there have been no previous attempts to analyze the cumulative effect of multiple adversities in combination on SUDI risk.

Methods: Based on sociological theories of social exclusion, a multidimensional framework capable of producing an overall measure of family-level social vulnerability was developed, accounting for both increasing disadvantage with increasing prevalence among family members and effect of family structures. This framework was applied retrospectively to all cases of SUDI that occurred in Queensland between 2010 and 2014. Additionally, an exploratory factor analysis was performed to investigate whether differing “types” of vulnerability could be identified.

Results: Increased family vulnerability was associated with four major known risk factors for sudden infant death: smoking, surface sharing, not-breastfeeding and use of excess bedding. However, families with lower levels of social vulnerability were more likely to display two major risk factors: prone infant sleep position and not room-sharing. There was a significant positive relationship between family vulnerability and the cumulative total of risk factors. Exploratory factor analysis identified three distinct vulnerability types (chaotic lifestyle, socioeconomic and psychosocial); the first two were associated with presence of major SUDI risk factors. Indigenous infants had significantly higher family vulnerability scores than non-Indigenous families.

Conclusion: A multidimensional measure that captures adversity across a range of indicators highlights the need for proportionate universalism to reduce the stalled rates of sudden infant death. In addition to information campaigns continuing to promote the importance of the back-sleeping position and close infant-caregiver proximity, socially vulnerable families should be a priority population for individually tailored or community based multi-model approaches.

Improving infant sleep safety via electronic health record communication: a randomized controlled trial

BACKGROUND

With increased use of telehealth, interventions to improve infant sleep environments have not been explored. This study sought to assess the feasibility and efficacy of using electronic health record patient portals to transmit photographs of infant sleep between mothers and healthcare professionals as part of an intervention to promote sleep environments consistent with AAP guidelines.

METHODS

One hundred eighty-four mother-newborn dyads consented to participate in a randomized trial requiring patient portal registration within 1 month of delivery. We first assessed feasibility as measured by a) the proportion of consented mothers enrolling in the portal and b) maternal adherence to prompts to submit photographs of their infant sleeping to the research team through the patient portal. Intervention group mothers were prompted at 1 and 2 months; controls were prompted only at 2 months. Efficacy was determined via research assistant review of submitted photographs. These assistants were trained to detect sudden unexplained infant death risk factors utilizing AAP guidelines. Standardized feedback was returned to mothers through the patient portal. We used Fisher's Exact test to assess group differences in guideline adherence at 2 months.

RESULTS

One hundred nine mothers (59%) enrolled in the patient portal and were randomized to intervention (N = 55) and control (N = 54) groups. 21 (38, 95% CI 25-52%) intervention group participants sent photographs at 1 month and received personalized feedback. Across both groups at 2 months, 40 (37, 95% CI 28-46%) sent photographs; 56% of intervention group participants who submitted photographs met all safe sleep criteria compared with 46% of controls (difference 0.10, 95% CI - 0.26 to 0.46, p = .75). Common reasons for guideline non-adherence were sleeping in a room without a caregiver (43%), loose bedding (15%) and objects (8%) on the sleep surface.

CONCLUSIONS

Utilizing the patient portal to individualize safe infant sleep is possible, however, we encountered numerous barriers in this trial to assess its effects on promoting safe infant sleep. Photographs of infants sleeping showed substantial non-adherence to AAP guidelines, suggesting further needs for improvement to promote safe infant sleep practices.

TRIAL REGISTRATION

Name: Improving Infant Sleep Safety With the Electronic Health Record; Clinicaltrials.gov: NCT03662048 ; Date of Registration: September 7, 2018; Data Sharing Statement: None.

Mother-Infant Co-Sleeping and Maternally Reported Infant Breathing Distress in the UK Millennium Cohort

Mother-infant co-sleeping or bed sharing is discouraged by health organisations due to evidence that it is associated with unexplained sudden infant death. On the other hand, there is evidence that it should theoretically be beneficial for infants. One line of this evidence concerns breathing regulation, which at night is influenced by the rocking movement of the mother's chest as she breathes. Here, the hypothesis that mother-infant co-sleeping will be associated with a lower probability of infant breathing distress is tested in the UK Millennium Cohort Study (n = 18,552 infants). Maternal, infant, family, and socio-economic covariates were included in logistic regression analysis, and in a machine learning algorithm (Random Forest) to make full use of the number of variables available in the birth cohort study data. Results from logistic regression analysis showed that co-sleeping was associated with a reduced risk of breathing difficulties (OR = 0.69, p = 0.027). The Random Forest algorithm placed high importance on socio-economic aspects of infant environment, and indicated that a number of maternal, child, and environmental variables predicted breathing distress. Co-sleeping by itself was not high in the Random Forest variable importance ranking. Together, the results suggest that co-sleeping may be associated with a modest reduction in risk of infant breathing difficulties.